Respiratory Flashcards
(170 cards)
1
Q
How prevalent is lung cancer?
A
3rd after breast and prostate
2
Q
What are the types of lung cancer?
A
Non - small cell:
- SCC
- Adenocarcinoma
- Large-cell carcinoma
Small- cell carcinoma
3
Q
What are some signs of lung cancer?
A
- SOB
- Cough
- Haemoptysis
- Finger clubbing
- Recurrent pneumonia
- Weight loss
- Lymphadenopathy (supraclavicular lymph nodes)
4
Q
What are the investigations for lung cancer?
A
CXR (hilar enlargement, peripheral opacity, PE, collapse)
Staging CT (chest, abdo, pelvis contrast enhanced for staging, check lymph node involvement and metastasis, contrast enhanced)
PET CT (inject radioactive tracer (attached to glucose molecules) and taking images using CT scanner and gamma ray detector - shows areas of increased metabolic activity
Bronchoscopy with endobronchial ultrasound (EBUS) - endoscopy of airway with US at end of scope for detailed assessment of tumour and US guided biopsy
Histological diagnosis
5
Q
Who is present at an MDT for lung cancer?
A
Surgeons
Oncologists
Radiologists
Pathologists
6
Q
What is offered first line in non-small cell lung cancer? What else can be offered?
A
Sugery - lobectomy or segmentectomy or wedge resection
RT can also be curative when early enough
Adjuvant chemo
7
Q
What is offered first line in small cell lung cancer?
A
Chemotherapy and RT
8
Q
What treatment can be used as part of palliative treatment in lung cancer?
A
Stents or debulking to relieve bronchial obstruction
9
Q
What are the extrapulmonary manifestations of lung cancer?
A
Recurrent laryngeal nerve palsy - hoarse voice as cancer presses on recurrent laryngeal nerve as it passes through the mediastinum
Phrenic nerve palsy - weak diaphragm due to nerve compression
SVC obstruction - facial swelling, difficulty breathing, distended veins - “Pemberton’s sign” = raising of hands over face causes cyanosis
Horners - compression of sympathetic ganglion, partial ptosis, anhidrosis and miosis caused by Pancoast’s tumour
SIADH - caused by ectopic ADH from small cell lung cancer causing hyponatraemia
Cushing’s syndrome - caused by ectopic ACTH from small cell lung cancer
Hypercalcaemia from ectopic parathyroid hormone from a squamous cell carcinoma
Limbic encephalitis - paraneoplastic syndrome small cell lung cancer causes antibodies to brain tissue (specifically limbic system) = short term mem impairment, hallucinations, confusion and seizures (associated with anti-Hu antibodies)
Lambert-Eaton myasthenic syndrome
10
Q
What paraneoplastic syndrome can occur from small cell lung cancer?
A
SIADH - hyponatraemia
ACTH release - Cushing’s
11
Q
What paraneoplastic syndrome can occur due to squamous cell carcinoma?
A
Hypercalcaemia from ectopic PTH
12
Q
What is Lambert-Eaton Myasthenic Syndrome?
A
Antibodies against small cell lung cancer which damage motor neurones (specifically voltage-gated calcium channels on presynaptic terminals)
Leading to weakness in:
Proximal muscles
Intraocular muscles causing diplopia
Levator muscles in the eyelid causing ptosis
Pharygeal muscles causing slurred speech and dysphagia
May also have dry mouth, blurred vision, impotence and dizziness due to autonomic dysfunction
In older smokers with symptoms of Lambert-Eaton syndrome consider small cell lung cancer
13
Q
Where does meothelioma affect?
A
Mesothelial cells of lung pleura
14
Q
What is mesothelioma associated with?
A
Asbestos inhalation (long latency period - 45 years)
Prognosis is poor - chemo can improve but essentiallt palliative
15
Q
What are the 3 types of pneumonia?
A
Hospital acquired (48hrs after admission)
Community acquired
Aspiration pneumonia
16
Q
How does pneumonia present?
A
SoB
Productive cough
Fever
Haemoptysis
Pleuritic chest pain
Delerium
Sepsis
17
Q
What are the signs of pneumonia?
A
- Tachypnoea
- Tachycardia
- Hypoxia
- Hypotension
- Fever
- Confusion
- Bronchial breath sounds (harsh breath sounds equally loud on inspiration/expiration)
- Dullness to percussion
18
Q
How is the CURB-65 score measured? (CRB-65 used out of hosp - if above 0 refer to hosp)
A
C – Confusion (new disorientation in person, place or time)
U – Urea > 7
R – Respiratory rate ≥ 30
B – Blood pressure < 90 systolic or ≤ 60 diastolic.
65 – Age ≥ 65
19
Q
What CURB-65 score would you consider admitting?
A
> or = 2 (predicts mortality)
20
Q
What are some common causes of pneumonia?
A
Streptococcus pneumoniae (50%)
Haemophilus influenzae (20%)
21
Q
When is Moraxella catarrhalis seen causing pneumonia?
A
Immunocompromised patients or those with chronic pulmonary disease
22
Q
When is pseudomonas aeruginosa/ S. aureus seen to cause pneumonia?
A
CF
23
Q
What is atypical pneumonia?
A
- Organism cannot be cultures/detected on gram stain
- Don’t respond to penicillins
- Do respond to macrolides (e.g. clarithomycin)/fluroquinolones (e.g. levofloxacin) or tetracyclins (e.g. doxycycline)
24
Q
What are some causes of atypical pneumonia?
A
Legionella pneumophilia
Mycoplasma pneumonia
25
How does legionella pneumophilia present? What is it normally caused by?
Hyponatraemia by causing **SIADH** (caused by infected water supplies / air conditioning units)
26
How does pneumonia caused by Mycoplasma pneumoniae present?
**Rash** - erythema multiforme (pink rings with pale centres = **target lesions**) also causes **neurological symptoms**
27
What are **three other causes** of **atypical pneumonia**? How do they present / what are they caused by?
**Chlamydophilia pneumoniae** - school aged child with mild / moderate chronic pneumonia and wheeze (may also not be caused)
**Coxiella burnetii** AKA "**Q fever**" - linked to exposure to animals / bodily fluids (usually farmer with flu like illness)
**Chlamydia psittaci** - from infected birds (parrot owners)
28
How can the **5 causes** of **atypical pneumonia** be remembered?
**Lesions of psittaci MCQs**
**L**egionella pneumophila
Chlamydia **p**sittaci
**M**ycoplasma pneumoniae
**C**hlamydophila pneumoniae
Coxiella burnetii = **Q** fever
29
When does pneumonia caused by pneumocystis jiroveci present?
In **immunocompromised** patients
**Poorly controlled HIV** with low CD4 count
30
How does PCP present?
Dry cough without sputum
SOB on exertion
Night sweats
31
What is the treatment of PCP?
**Co-trimoxazole** (trimethoprim / sulfamethoxazole) = "Septrin"
32
What are the investigations for pneumonia?
CXR
FBC (for raised WCC)
U&Es (for urea)
CRP (for inflammation)
Sputum cultures
Blood cultures
Urinary antigens (for suspected legionella and pneumococcal)
33
When may patients with pneumonia not show an inflammatory response?
**Immunocompromised** (normally WBC and CRP are raised in proportion to severity of infection - WBC respond faster)
34
How is **mild and moderate CAP treated** respectively?
Amoxicillin / macrolide
(both if moderate)
Severe may require IV abx
35
What are some **complications for pneumonia**?
Sepsis
PE
Empyema
Lung abscess
Death
36
In **spirometry** what is FEV1?
FVC?
**FEV1** = forced expiratory volume in 1 second (reduced in obstruction)
**FVC** = Forced vital capacity, amount exhaled after full inhalation (reduced in restriction)
37
What Spirometry result indicates **obstruction** as the cause?
FEV1 is \<75% of FVC
38
What are some **causes of obstruction**?
**Asthma**
**COPD** (test for reversibility with brochodilator e.g. salbutamol)
39
What FEV1/FVC ratio indicates restrictive disease?
\>75%
40
What are some **causes of restrictive lung disease**?
**ILD**
**Neurological**
**Scoliosis**
**Obesity**
41
How is a **peak flow performed**? What is it typically used for?
Measured using a **peak flow meter** (useful in obstructive lung disease e.g. asthma)
Patient stands tall, breaths in, makes a seal around device, blows as fast and hard as possible.
Take **three** attempts and record the best one
Usually recorded as "**percentage of predicted**"
42
How is peak flow put into context?
**Percentage of predicted** based on sex, height and age
43
What is asthma?
**Chronic inflammation of the airways** causing **bronchoconstriction**
44
What causes the **bronchoconstriction** seen in asthma?
**Hypersensitivity** of the airways
45
What are some **triggers of asthma**?
- Infection
- Night time/early morning
- Exercise
- Animals
- Cold/damp
- Dust
- Strong emotions
46
What **presentation suggests asthma**?
- Episodic symptoms
- Diurnal variability (worse at night)
- Dry cough with wheeze
- History of other atopic conditions e.g. eczema, hayfever and food allergies
- FH
- Bilateral widespread "polyphonic" wheeze
47
What **presentation indicates a diagnosis other than asthma**?
- Wheeze related to coughs / colds = viral
- Isolated / productive cough
- No response to treatment
- Unilateral wheeze
48
What are the **investigations for asthma diagnosis**?
**- Spirometry with bronchodilator reversibility**
**- Fractional exhaled nitric oxide**
If uncertainty following then:
- Peak flow variability (several times a day for 2-4 weeks)
- **Direct bronchial challenge test** with **histamine** and **methacholine**
49
What are the steps of medication for asthma? (NICE)
**As required SABA** (short acting beta 2 adrenergic receptor agonists e.g. salbutamol - effect only lasts for an hour / two acts on bronchioles used as "rescue" medication)
**Regular** inhaled low dose **corticosteroid** (e.g. beclometasone used as "preventer")
**Leukotriene receptor antagonist** (e.g. oral montelukast and check response) / **LABA** (e.g. salmetarol)
CONSIDER CHANGING TO A MART REGIME (combining inhaler containing a low dose inhaled corticosteroids and fast acting LABA - **single inhaler** used as preventer and reliever.
**Titrate inhaled corticosteroids up** to "moderate dose"
Consider increasing ICS higher or add **oral theophylline** or inhaled **LAMA** (e.g. **tiotropium**)
Refer to specialist
50
What are leukotrienes and what do they do?
Product of the **immune** system and cause **inflammation, bronchoconstriction and mucus secretion** (leukotriene receptor antagonists work against this)
51
What is maintenance and reliever therapy?
MART
ICS and LABA - replacing all other inhalers using both regularily and as relief
52
What does the BTS offer as 3rd line medication instead of Leukotriene receptor antagonist?
**LABA**
53
How do:
**Long-acting muscarinic antagonists** (LAMA e.g. **tiotropium**)
**Theophylline**
work?
**LAMA** = block acetylcholine receptors (usually stimulated by parasympathetic nervous system causing contraction of bronchial smooth muscles)
**Theophylline** = relaxes smooth muscle and reduces inflammation (has **narrow therapeutic window** can be roxic in excess - monitoring of theophylline levels is needed - done 5 days after starting and 3 days after each dose changes)
54
What are some additional things useful for asthmatics?
What are the rules of the treatment 'ladder'?
- Individual asthma self-management plan
- Yearly flu jab
- Yearly asthma review
- Advise exercise and avoid smoking
Ladder = start at **most appropriate step** for severity of symptoms, review at regular intervals, step up and down based on symptoms, achieve no symptoms or exacerbation on lowest dose, check inhaler technique at review
55
What is an acute exacerbation of asthma?
**Rapid deterioration in symptoms**
Triggered by any typical triggers e.g. infection, exercise, cold, weather
56
How does **acute asthma attacks present**?
Worsening of SoB
Use of accessory muscles
Fast RR (tachypnoea)
Symmetrical **expiratory** wheeze on auscultation
Chest can sound "tight" on auscultation with reduced air entry
57
What is moderate asthma?
PEFR 50-75% predicted
58
What is severe asthma?
PEFR 33-50% predicted
RR \>25
HR \>110
**Unable to complete full sentences**
59
What is life threatening asthma?
PEFR \<33%
Sats \<92%
Becomming tired
No wheeze - **silent chest**
Haemodynamic instability (i.e. shock)
60
What is the treatment of **moderate asthma**?
NEB **SABA** and NEB **IPRATROPIUM BROMIDE**
Steroids (prednisolone or IV hydrocortisone) - continued for 5 days
Abx if bacterial infection suspected
61
What is the treament of severe asthma?
Oxygen (sats 94-98%)
**Aminophylline** infusion
Maybe IV salbutamol
62
What is the treatment of **life threatening asthma**?
IV **magnesium sulphate** infusion
Admission to HDU
**Intubation** in worse cases
63
What acute asthma medications are under senior guidance?
**Aminophylline**
**IV salbutamol**
**IV magnesium**
64
How are the ABGs in acute asthma, initially then later on?
**Respiratory alkalosis** as tachypnoea causes drop in CO2
A normal pCO2 or hypoxia indicates life threatening asthma
**Respiratory acidosis** due to high CO2 is a very bad sign in asthma
65
How to **monitor the response to asthma treatment**?
Monitor **RR**
Monitor **Respiratory effort**
Monitor **Peak flow**
Monitor **oxygen saturations**
Chest auscultation
66
What electrolyte needs to be monitored when on **salbutamol**?
**Serum potassium** (causes hypokalaemia as cells absorb potassium)
67
What is a cardiac side effect of salbutamol?
Tachycardia
68
What is COPD?
**Non-reversible** long term **deterioration in air flow** through lungs caused by damage to lung tissue (almost always **result of smoking**)
69
How does **COPD present?**
- Chronic SoB
- Cough
- Sputum production
- Wheeze
- Recurrent resp infections
- NO CLUBBING and unusual for it to cause haemoptysis or chest pain
70
Does COPD normally cause haemoptysis?
Not usually
71
What scoring system can be used for breathlessness?
**MRC Dyspnoea Scale**
72
What would grade 5 indicated for MRC dyspnoea score?
Unable to **leave house due to breathlessness** (grade 1 = breathless on strenuous exercise)
73
How is **COPD diagnosed**?
**Clinical presentation** plus **spirometry**
74
What pattern does **COPD show on spirometry**?
**Obstructive** picture with **no reversibility**
75
How is the severity of COPD graded?
FEV1
If **\>80%** then **stage 1**
if **\<30%** then **stage 4**
76
What are the **other** investigations for **COPD**?
**CXR** to exclude lung cancer
**FBC** for polycythaemia (response to chronic hypoxia) or anaemia
**BMI** as baseline to assess later weight loss or weight gain (steroids)
**Sputum cultures** to assess for chronic infection such as pseudomonas
**ECG** and **Echo** for heart function
**CT** thorax for diagnosis of cancer, fibrosis or bronchiectasis
**Serum alpha-1 antitrypsin** to look for deficiency
**Transfer factor for carbon monoxide** (TLCO) is decreased in COPD and gives indication about severity of disease
77
What is the first step of managing COPD?
Advise stop smoking
78
What additional preventative measures should be advise for COPD?
**Pneumococcal** and **annual flu** vaccine
79
What is the **first line medication for COPD**?
**SABA** or short acting antimuscarinic (e.g. **ipratropium bromide**)
80
What is the 2nd line medication for patients with COPD:
Non-asthmatic features:
Asthmatic features:
**Non-asthmatic features:** LABA plus LAMA combi inhalor
**Asthmatic features** (steriod responsive): LABA plus ICS combi inhalor (e.g. fostair, symbicort and seretide)
81
What are the **additional options** in **more severe COPD**?
**Nebulisers** (salbutamol / ipratropium)
Oral **theophylline**
Oral **mucolytic therapy** to break down sputum (e.g. carbocisteine)
Long term prophylactic antibiotics (e.g. **azithromycin**)
LTOT
82
When is LTOT offered to patients with COPD?
When problems such as **chronic hypoxia, polycythaemia, cyanosis** or **heart failure** secondary to cor pulmonale (Cant be used if they smoke)
83
What **indicates an exacerbation of COPD**?
Acute worsening of symptoms of **cough, SoB, sputum production and wheeze**
Usually triggered by viral / bacterial infection
84
How does CO2 make blood acidotic?
What does that indicate in COPD?
Breaks down into **carbonic acid** (H2CO3)
Low pH and raised pCO2 suggests acute **retaining**
85
What is type 1 and type 2 respiratory failure respectively?
1 is low oxygen
2 is low oxygen and high CO2
86
How to investigate acute exacerbation of COPD?
**CXR** to look for **pneumonia**
**ECG** to look for **arrythmia**
**FBC** to look for **infection**
**U&E** to check **electrolytes**
**Sputum culture**
**Blood culture** if septic
87
Why is too much oxygen in COPD dangerous?
**Supresses respiratory drive**
88
What are **venturi masks**?
Masks which are designed to deliver a specific percentage of oxygen (environmental contains 21%)
89
What are the o2 sats for a COPD patient who is **retaining CO2** or not retaining **O2**?
Retaining = 88-92
Not retaining = \>94
90
How can you tell if a patient with COPD is retaining CO2?
Their bicarb is high to compensate
91
What is the treatment for acute exacerbation of COPD at home?
**Prednisolone** 30mg once daily
Regular inhalers / NEBs
**Abx** if evidence of infection
92
What is the treatment of **acute exacerbation of asthma** in hospital?
Neb bronchodilators (salbutamol / ipratropium)
Steroids (200mg hydrocortisone/ 30mg oral prednisolone)
ABx (if infection)
Physio (help clear infection)
93
What are the **options** for treatment of **severe acute exacerbation** of COPD**?**
IV **aminophylline**
**NIV**
**Intubation / ventilation** with admission to intensive care
**Doxapram** can be used as respiratory stimulant where NIV / intubation isnt appropriate
94
What are the non-invasive ventiation options?
BiPAP
CPAP
95
What does Bipap stand for?
**Bilevel positive airway pressure** (high and low pressure corresponds to patients inspiration and expiration - keeps some pressure during expiration to prevent airway collapse)
**Used in type 2 resp failure**, typically due to COPD
96
What are the **contraindications** for **BiPAP**?
Untreated pneumothorax / structural abnormality affecting face, airway or GI tract
97
What does CPAP stand for? What does it involve?
Continuous positive airway pressure
Continuous air blown into the lungs keeping airways expanded - **maintains airways when they are prone to collapse**
98
What are some indications for CPAP?
- Obstructive sleep apnoea
- Congestive cardiac failure
- Acute pulmonary oedema
99
What is ILD?
Term used to describe conditions which affect **lung parenchyma** causing **inflammation** and **fibrosis**
100
How is ILD diagnosed?
Clinical **features** and **high resolution CT of thorax**
101
What would a **HRCT** show for **ILD**?
"**ground glass**" appearance
102
If a diagnosis for ILD is unclear what can be done?
**Lung biopsy** taken and **confirm diagnosis on histology**
103
What is the **management** in **general for ILD**?
**Limited management options** as damage is **irreversible**
104
What are the treatment options of ILD?
- Treat **underlying cause**
- **Home oxygen when hypoxic** at rest
- **Stop smoking**
- **Physio and pulmonary rehab**
- **Penumococcal and flu vaccine**
- **Advanced care planning**
- **Lung transplant is an option** but risks and benfits need consideration
105
What are some types of ILD?
**Idiopathic pulmonary fibrosis**
**Drug induced pulmonary fibrosis**
**Secondary pulmonary fibrosis**
**Hypersensitivity pneumonitis**
**Cryptogenic organising pneumonia**
**Asbestosis**
106
What is idiopathic pulmonary fibrosis? How does it present?
- **Progressive f****ibrosis with no clear cause**
- **Insidious onset** dry cough or more than 3 months
- Affects adults \> 50 years old
- Examination = bibasal fine **inspiratory crackles** and finger **clubbing**
- Life expectancy **2-5 years from diagnosis**
107
Which **medications** can **slow progression** of **idiopathic pulmonary fibrosis**?
**Pirfenidone** (antifibrotic and anti-inflammatory)
**Nintedanib** (monoclonal antibody targeting **tyrosine kinase**)
108
What drugs can cause pulmonary fibrosis?
- Amiodarone
- Cyclophosphamide
- Methotrexate
- Nitrofurantoin
109
What can cause secondary pulmonary fibrosis?
Alpha-1 antitrypsin deficiency
- RA
- SLA
- Systemic sclerosis
110
What is hypersensitivity pneumonitis? What is it also known as?
Inflammation of lung parenchyma due to environmental allergens - **type 3 hypersensitivity reaction**
## Footnote
**Extrinsic allergic alveolitis**
111
What would bronchoalveolar lavage show for hypersensitivity pneumonitis? How is it performed?
Raised lymphocytes and mast cells
Collecting cells during **bronchoscopy** by washing airways with fluid then collecting
112
What was **cryptogenic organising pneumonia** previously known as?
What causes it?
How does it present?
How is it diagnosed and treated?
**Bronchiolitis obliterans organising pneumonia**
Causes **focal area of inflammation** in lungs
**Triggers** = infection, inflammatory disorders, medications, radiation or environmental toxins or allergens (can be idiopathic)
**Presentation** = SoB, cough, fever and lethargy
**Diagnosis** = lung biopsy
**Treatment** = systemic corticosteroids
113
What can cause hypersensitivity penumonitis? How is it managed?
- Bird droppings (bird fanciers lung)
- Mouldy spores in hay (reaction to mouldy spores in hay)
- Mushroom antigens
- Malt workers lung (reaction to mould on barley)
Management = remove allergen, give O2 and steroids
114
What can inhalation of asbestos cause?
Lung fibrosis
Pleural thickening and pleural plaques
Mesothelioma
Adenocarcinoma
115
What is the difference between an exudate/transudate?
Exudate = high protein count
Transudate = low protein count
116
What causes an exuative effusion?
Inflammation:
- Lung cancer
- Pneumonia
- RA
- TB
117
What causes a transudative exudate?
Congestive cardiac failure
Hypoalbuminaemia
Hypothyroidism
Meig's syndrome (right sided pleural effusion with ovarian malignancy)
118
How does a pleural effusion present?
SoB
Dullness to percuss over the effusion
Reduced breath sounds
Tracheal deviation away from effusion
119
What appear on the xray for pleural effusion?
- Blunting of the costophrenic angle
- Fluid in the lung fissures
- Meniscus
- Deviation of trachea and mediastinum if its a massive effusion
120
What other investigation can be used for pleural effusion?
Sample of pleural fluid for analysis for **protein count, cell count, pH, glucose**
121
What are the treatment options for pleural effusions?
**Pleural aspiration** - put needle in and aspirate (temporary)
**Chest drain** - drain effusion and prevent recurring
(conservative may be appropriate as small effusions will resolve with treatment of underlying cause)
122
What is empyema?
How is it treated?
Infected pleural effusion
**Pleural aspiration** shows: pus, acidic pH \<7.2, low glucose and high LDH
**Chest drain** treats
123
What are some causes of pneumothorax?
- Spontaneous
- Trauma
- Iatrogenic e.g. lung biopsy
- Lung pathology e.g. infection, asthma or COPD
124
What is the investigation for pneumothorax?
Erect chest X-ray
125
What is the **management** of **pneumothorax**?
If **no SOB** and there is a **\< 2cm rim of ai**r on the chest xray then **no treatment required** as it will spontaneously resolve. **Follow up in 2-4 weeks** is recommended.
If **SOB** and/or there is a **\> 2cm rim of air** on the chest xray then it will require **aspiration and reassessment**.
If **aspiration fails twice** it will **require a chest drain**.
**Unstable patients** or **bilateral** or **secondary pneumothoraces generally require a chest drain**.
126
What causes **tension pneumothorax**?
Trauma to chest wall causing **one-way valve** letting air in but not out (during inspiration air is drawn into pleural space and during expiration air is trapped)
127
What are some **signs of tension pneumothorax**?
**Tracheal deviation away** from side of penumothorax
**Reduced air entry** to affected side
**Increased resonant** to percussion on affected side
**Tachycardia**
**Hypotension**
128
What is the **management of tension pneumothorax**?
Large bore callula into 2nd intercostal space, mid clavicular line
129
Where is a chest drain inserted (for definitive management)?
**5th intercostal space** (inferior nipple line)
**Mid axillary line** (or lateral edge of **latissimus dorsi**)
**Anterior axillary line** (or lateral edge of **pectoris major**)
130
What are some risk factors for PE?
- Immolbilty
- Recent surgery
- Long haul flights
- Pregnancy
- HRT with oestrogen
- Malignancy
- Polycythaemia
- SLE
- Thrombophilia
131
What is commonly used at **VTE prophylaxis in hospital**?
**LMWH** (enoxaparin)
132
What are some contraindications for LMWH?
Active bleeding
Existing anticoagulation with warfarin or a NOAC
133
What is the main contraindication for compression stockings?
Peripheral arterial disease
134
What are the **presenting features of PE**?
**SoB**
**Cough** (maybe haemoptysis)
**Pleuritic chest pain**
**Hypoxia**
**Tachycardia**
**Raised resp rate**
**Low grade fever**
**Haemodynamic instability causing hypotension**
135
What does the **Wells score tell you**?
Risk of a patient presenting with symptoms actually having a DVT or PE
136
In a suspected PE how do you decide if you CTPA?
On outcome of Wells score
137
What are the two main options for diagnosing PE?
**CTPA** = chest CT with IV contrast highlighting pulmonary arteries
**VQ scan** = using inhaled radioactive isotopes, injected isotopes and gamma camera to compare **ventilation** with **perfusion** (used in patients with **renal impairment**, **contrast allergy** or at risk from radiation)
138
When would a VQ scan be used over a CTPA to diagnose PE?
What does a ABG show in PEs?
Contrast allergy
**Resp alkalosis** (high resp rate causes them to "blow off" extra CO2
139
What is the **supportive management for a PE**?
**- Admit to hospital**
**- Oxygen**
**- Analgesia**
**- Monitor for deterioration**
140
What is the inital management for PE?
**Apixaban / Rivaroxaban**
LMWH (e.g. in antiphospholipid syndrome) e.g. enoxaparin or dalteparin
141
Which **long term anticoagulants** are available for VTE?
**Warfarin, DOAC or LMWH**
142
What are some examples of some DOACs
**Apixaban**
**Dabigatran**
**Rivaroxaban**
143
How long is anticoagulation continued for post PE?
**3 months** if reversible cause
**\> 3 months** if cause is unclear
**6 months** in active cancer
(**LMWH** is first line in pregnancy / cancer)
144
What can be used for patients with a **PE and haemodynamic compromise**?
**Thrombolysis** = fibrinolytic agent via **cannula** or directly into **pulmonary arteries** (significant risk of bleeding)
e.g. streptokinase, altepase, tenecteplase
Can also be given into **pulmonary arteries** using central catheter = **catheter-directed thrombolysis**
145
What are some **causes of pulmonary hypertension**?
- Primary **pulmonary hypertension**
- Connective tissue disease e.g. SLE
- **Left heart failure** due to MI
- Pulmonary vascular disease e.g. **pulmonary embolism**
- **COPD**
- **PE**
146
What are some signs and symptoms of pulmonary hypertension?
**Shortness of breath**
- Syncope
- Tachycardia
- Raised JVP
- Hepatomegaly
- Peripheral oedema
147
What are the ECG changes in pulmonary hypertension?
- **Right ventricular hypertrophy** (larger R waves on right sided chest leads V1-V3)
- **Right axis deviation**
- **Right BBB**
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What are the **CXR changes** in **pulmonary hypertension**?
- **Dilated pulmonary arteries**
- **Right ventricular hypertrophy**
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What are some **other investigations** for **pulmonary hypertension**?
Raised NT-proBNP blood test results right ventricular failure
Echo to estimate pulmonary artery pressure
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What can **pulmonary hypertension be treated with**?
**_Primary pulmonary hypertension_**
**IV prostanoids** (e.g. epoprostenol)
**Endothelin receptor antagonists** (e.g. macitentan)
**Phosphodiesterase-5 inhibitors** (e.g. sildenafil)
**Supportive** = respiratory failure, arrhythmias and HF
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What is sarcoidosis? What does it cause?
**Granulomatous** inflammatory condition - granulomas = full of **macrophages**
**Extra-pulmonary manifestations** e.g. **erythema nodosum** and **lymphadenopathy**
Symptoms can be asymptomatic to life-threatening
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Who typically gets sarcoidosis?
20-40 or \>60
Women more frequently
Black people
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Where does sarcoidosis affect and how does it manifest?
**Lungs** (mediastinal lymphadenopathy, pulmonary fibrosis, pulmonary nodules)
**Systemic** (fever, fatigue, weight loss)
**Liver** (liver nodules, cirrhosis, cholestasis)
**Eyes** (conjunctivitis, uveitis, optic neuritis)
**Skin** (erythema nodosum - tender, red nodules on shins caused by inflammation of subcut fat, lupus pernio - raised, purple skin lesions on cheeks and nose, granulomas develop in scar tissue)
**Heart** (BBB, heart block)
**Kidneys** (stones due to hypercalcaemia, nephrocalcinosis, interstitial nephritis)
**CNS** (nodules, pituitary involvement e.g. diabetes insipidus, encephalopathy)
**Peripheral nervous system** (facial nerve palsy, mononeuritis multiplex)
**Bones** (arthralgia, arthritis, myopathy)
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What is **Lofgren's syndrome**?
Specific presentation of sarcoidosis, characterised by:
- Erythema nodosum
- Bilateral hilar lymphadenopathy
- Polyarthralgia
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What may also present like sarcoidosis?
- TB
- Lymphoma
- Hypersensitivity pneumonitis
- HIV
- Toxoplasmosis
- Histoplasmosis
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What is the screening test for sarcoidosis?
**Raised ACE**
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What blood tests may also be raised for sarcoidosis?
Hypercalcaemia
Raised **serum soluble interleukin-2 receptor**
Raised CRP
Raised Immunoglobulins
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What should chest XR show for sarcoidosis?
**Hilar lymphadenopathy**
High-resolution CT thorax shoes **hilar lymphadenopathy** and **pulmonary nodules**
**MRI** can show **CNS involvement**
**PET scan** shows active inflammation in affected areas
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What is the **gold standard** for diagnosing sarcoidosis?
**Histology from a biopsy** from bronchoscopy with US guided biopsy
Histology = **non-caseating granulomas** with **epithelioid cells**
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What are the tests for other organs in sarcoidosis?
**U&Es** for kidney involvement
**Urine dip** for proteinuria
**LFTs** for liver involvement
**Opthamology** for eye involvement
**ECG** and e**cho** for heart involvement
**US abdo** for liver / kidney involvement
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What is the **treatment** for **sarcoidosis**?
**Oral steroids** (and bisphosphonates) are 1st line
Second line are **methotrexate** or **azathioprine**
**Lung transplant** is rarely required in severe pulmonary disease
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What is the **prognosis of sarcoidosis** (unknown aetiology)?
Spontaneous resolvement in around 60% in patiens
Some progress to **pulmonary fibrosis** and **pulmonary hypertension**
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What is obstructive sleep apnoea caused by?
**Collapse of the pharyngeal airway during sleep**
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What are some risk factors of obstructive sleep apnoea?
Middle age
Male
Obese
Alcohol
Smoking
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What are some **features of obstructive sleep apnoea**?
- Episodes during sleep
- Snoring
- Morning headache
- Daytime sleepiness
- Unrefreshed sleep
- Concentration problems
- Reduced O2 sats during sleep
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What scoring system can be used to **assess symptoms** of **sleepiness** associated with **obstructive sleep apnoea**?
**Epworth sleepiness scale**
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How to manage sleep apnoea?
Referral to **ENT specialist** or **specialist sleep clinic** for sleep studies (pt sleeps whilst lab staff monitor oxygen sats, HR, RR and breathing to establish any apnoea episodes)
**Conservative:** Stop smoking, drinking, lose weight
**CPAP**
**Surgery** - restructuring of soft palete and jaw (**uvulopalatopharyngoplasty**)
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What features describes poorly controlled asthma?
- **Difficulty sleeping** because of symptoms
- Interfering with usual **activities**
- **Decreasing PEFR**
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How can cause of peak flow deterioration be checked?
- Check adherance to treatment
- Smoking?
- New pets/job
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What can be included in educating asthma patients?
- Review inhaler technique
- Step up management: add Leukotriene receptor antagonist (NICE)
- Smoking cessation
- Avoid triggers
